Schedule Appointment

Schedule an Appointment

To schedule an appointment, please complete the form below and our office manager will reach out to you for scheduling
Name

First NameMiddle NameLast Name
Sex
Date of Birth

MonthDayYear
Parent/Guardian Name

First NameLast Name
Contact Number:

Area CodePhone Number
E-mail
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Are you requesting:
Do you wish to have your child seen at school if the school permits it?
If yes, what school does your child attend?
Referring Physician
Phone Number

Area CodePhone Number
Primary Care Physician
Phone Number

Area CodePhone Number
Specialist
Phone Number

Area CodePhone Number
Taking any medications, currently?
If yes, please list it here
Reason For Referral/Concerns
Medical Diagnosis and History
Primary Health Insurance Company
Member ID
Group Number
Policy Holder Name
Policy Holder Date of Birth
Secondary Health Insurance Company
Secondary Member ID
Secondary Group Number
Secondary Policy Holder Name
Secondary Policy Holder Date of Birth
I, hereby, give consent for Little Feet Therapy to render skilled physical/occupational therapy services for my child. I am aware that all therapy services will be provided by a licensed physical or occupational therapist and that treatment is based on medical necessity.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I was notified of Little Feet Therapy’s Notice of Privacy Practices (HIPAA) and if I would like a copy of these PrivacyPractices, I will request them by contacting by calling 704-931-8022.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I consent to the release of information by doctors, psychologists, counselors, teachers/school, other therapy providers; to include, but not limited to occupational, physical, speech, music, behavioral therapy, and all other facilities where my child has been treated and would hold information pertinent to their therapy plan of care to Little Feet Therapy. I also authorize Little Feet Pediatric Therapy. I also authorize Little Feet Therapy to release any medical or pertinent information to my child's growth and development to their doctors, psychologists, counselors, therapists, school,teachers, care/service coordinator, and the family members listed below: (You may revoke your authorization in writing at any time; this release is valid for three years from the date signed below.)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I give consent and authorization for Little Feet Therapy to verify. I understand that verification of benefits does not guarantee payment by the insurance company. I authorize Little Feet Therapy to submit claims to my insurance company and for my insurance company to release payment on my behalf to Little Feet Therapy. I understand that I am responsible for insurance deductibles, copays, coinsurance and amounts not covered by any insurance or payment provider. Payment will be made according to invoice. This invoice will be sent from Little Feet Therapy via email on a monthly basis. For payments made 30 days past the due date; a 25% late fee will be added and the account will be sent to a collections agency.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I consent and give permission to you and those acting under your authority to photograph/video and use the likeness of my child in connection with Little Feet Therapy including but not limited to posts on social media including Facebook and Instagram, printed marketing material and website posts.By signing below I certify that I am the parent or legal guardian of the child above, a minor. I release Little Feet Therapy, its parent, affiliates, officers, directors, agents and employees, and those acting under its authority, from all debts, claims and liabilities of any kind arising out of or in connection with the use and publication of the photograph/ likeness referred to above. The undersigned does hereby agree to hold Little Feet Therapy, its parent, affiliates, officers, directors, agents, and employees, and those acting under its authority, against loss from any claim, action, or demand that may be brought at any time by the above-named minor or by anyone acting on the minor's behalf for the purpose of enforcing a claim for damages on account of the use and publication of the minor's likeness and photograph.
Signature
I give permission to Little Feet Therapy to charge my credit card for services rendered and products purchased; to include, but not limited to, copays, coinsurance, and deductibles.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please enter you credit card information below. Your card will never be charged by Little Feet Therapy without your knowledge or receipt. We collect this information to keep on file for your and our convenience. It is for the processing of copays, deductibles, and coinsurance. HSA/FSA cards are permitted and welcomed.
Name

First NameLast Name
Credit Card Number
Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
CVC
Billing Zip Code
How did you find us?

Other
Should be Empty:

Schedule an Appointment